Maternal and perinatal death surveillance and response: a systematic review of qualitative studies

Abstract Objective To understand the experiences and perceptions of people implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries, and the mechanisms by which this process can achieve its intended outcomes. Methods In June 2022, we systematically searched seven databases for qualitative studies of stakeholders implementing maternal and/or perinatal death surveillance and response in low- and middle-income countries. Two reviewers independently screened articles and assessed their quality. We used thematic synthesis to derive descriptive themes and a realist approach to understand the context–mechanism–outcome configurations. Findings Fifty-nine studies met the inclusion criteria. Good outcomes (improved quality of care or reduced mortality) were underpinned by a functional action cycle. Mechanisms for effective death surveillance and response included learning, vigilance and implementation of recommendations which motivated further engagement. The key context to enable effective death surveillance and response was a blame-free learning environment with good leadership. Inadequate outcomes (lack of improvement in care and mortality and discontinuation of death surveillance and response) resulted from a vicious cycle of under-reporting, inaccurate data, and inadequate review and recommendations, which led to demotivation and disengagement. Some harmful outcomes were reported, such as inappropriate referrals and worsened staff shortages, which resulted from a fear of negative consequences, including blame, disciplinary action or litigation. Conclusion Conditions needed for effective maternal and/or perinatal death surveillance and response include: separation of the process from litigation and disciplinary procedures; comprehensive guidelines and training; adequate resources to implement recommendations; and supportive supervision to enable safe learning.


Introduction
Many low-and middle-income countries are still far from attaining the sustainable development goals to reduce maternal and child mortality; one of the main obstacles is poor quality of health care. 1 In 2004, the World Health Organization (WHO) recommended that all countries implement maternal death reviews, 2 and in 2013 recommended all countries implement maternal death surveillance and response, 3 to which perinatal deaths were added in 2016. 4 Guidance on maternal and perinatal death surveillance and response was published in 2021. 5 The existing programme theory, describing how the mortality audit cycle should function, is shown in Fig. 1 and Box 1. [2][3][4][5] In a survey of low-and middle-income countries, 85% (88/103) had a national policy to review all maternal deaths. 6 Most low-and middle-income countries that succeeded in reducing maternal and child mortality used some form of death reporting system to monitor progress, but only a minority used the full maternal and perinatal death surveillance and response cycle. 7 Implementation of maternal and perinatal death surveillance and response in low-and middle-income countries is challenging because resources are more constrained than in high-income settings, but the opportunities to achieve a significant impact are greater. Maternal death reviews can reduce maternal mortality by up to 35% (odds ratio; OR: 0.65; 95% confidence interval, CI: 0.55-0.77) and perinatal death reviews have been associated with a 30% reduction in perinatal mortality (OR: 0.70; 95% CI: 0.62-0.79). [8][9][10] However, these data from health facility studies represent a best-case scenario. When scaling up to the national level, the outcomes are more heterogeneous. For example, among 35 facilities that have been part of the South African Perinatal Problem Identification Programme for at least 5 years, perinatal mortality declined in four facilities, increased in five, and did not change in the remaining 26 facilities. 11,12 The reasons for this heterogeneity in effectiveness are unclear. Several scoping reviews describe different maternal and perinatal death surveillance and response processes in sub-Saharan Africa and low-and middle-income countries, some with contradictory interpretations. [13][14][15] While one review suggested that the most important mechanisms for accountability were disciplinary action, legal redress and social reprisals, 13 another review reported that fear of blame and punitive approaches undermined the process. 14 These reviews highlight the need for more research on death surveillance and review processes, the context in which they are conducted, 14 and the subjective experiences of individuals implementing maternal and perinatal death surveillance and response in different settings. 15 None of the previous reviews systematically analysed qualitative studies or took a realist approach to understanding why maternal and perinatal death surveillance and response systems achieve positive or negative outcomes in different contexts.
Therefore, in this systematic review, we aimed to understand the experiences of people implementing maternal and perinatal death surveillance and response in low-and middle-income countries. We sought to understand the mechanisms by which this process achieves (or fails to achieve) its intended outcomes, and the contexts that trigger these mechanisms.

Methods
We conducted a systematic review of qualitative studies. The protocol was registered on PROSPERO (PROSPERO 2021 CRD42021271527).

Literature search
We searched seven databases from their inception to June 2022: CINAHL, MED-LINE ® , Embase ® , ProQuest Dissertations and Theses, Global Index Medicus, Web of Science and Google Scholar. We used a pre-planned strategy including terms for maternal or perinatal death reviews from a Cochrane review 10 and a search filter for qualitative studies (see strategy in first data repository). 16

Study selection
Two reviewers independently screened titles and abstracts against the inclusion criteria: studies using qualitative data collection and analysis methods, including participants who were involved in implementation of any part of the maternal and perinatal death surveillance and response process in low-and middle-income countries -including verbal and/or social autopsy when these involved investigation of maternal or perinatal deaths. We had no language restrictions. The reviewers then assessed the full text of the selected studies. We resolved disagreements by discussion with a third reviewer.

Critical appraisal
One of the reviewers evaluated the quality of the included full-text articles using the Critical Appraisal Skills Programme tool for qualitative studies. 17 The second reviewer independently evaluated a randomly selected 10% of the included articles; we found no significant disagreements.

Data extraction and analysis
We imported studies into NVivo, version 12 (QSR International Inc., Burlington, MA, United States of America). We used a thematic synthesis approach: 18 two authors developed a preliminary coding frame based on a sample of studies and refined this further by discussion. Higher-order categories of codes were deductive (barriers and enablers) but lower-order categories were developed inductively and iteratively from the data in the texts. We coded subsequent stud-ies line by line, focusing on the results and discussion sections, and created new codes when considered necessary. We used the codes to develop descriptive themes. To develop higher-order analytical themes, we used a realist approach. 19 We recoded the included articles specifically looking for contexts, mechanisms, outcomes and context-mechanismoutcome configurations. 19,20 We used these configurations to construct flow diagrams showing causal links and to refine the programme theory for ma- All maternal and perinatal deaths should be reported to produce valid statistics on mortality.

Collecting information
A truthful and complete account of the patient's symptoms, treatment-seeking and management before their death should be obtained from verbal and/or social autopsy interviews, medical records and reports from health workers.

Reviewing and analysing information
The committee reviewing the account should reliably identify the cause of death and avoidable factors.

Recommending solutions
The committee should make effective recommendations to avoid recurrence of the same scenario.

Implementing changes
The recommendations made by the committee should be implemented.

Evaluating and refining
The implementation of the entire audit cycle should be monitored and, if necessary, changes should be made to achieve the desired goal of reducing maternal and perinatal mortality.

Systematic reviews
Maternal and perinatal death surveillance Merlin L Willcox et al.
ternal and perinatal death surveillance and response.

Studies included
The initial searches yielded a total of 5137 articles after removal of duplicates. After screening, we finally included 58 publications, reporting on 59 different studies (Fig. 2).  These studies included over 1891 participants from 30 lowand middle-income countries, ranging from community members to health workers and national-level stakeholders involved in implementation of maternal death reviews or maternal and perinatal death surveillance and response.
Most studies (34/59) focused on maternal deaths (25 on maternal death reviews and nine on maternal death surveillance and response), 19 included both maternal and perinatal deaths, and six studies considered only perinatal or neonatal deaths (Table 1; available at: https:// www .who .int/ publications/ journals/ bulletin/ ). The overall effectiveness of the process was perceived as good (improved quality of care or reduced mortality) in 16 studies, inadequate in 21 studies and mixed in five studies; the perceived effectiveness was not reported in 17 studies. All studies were of sufficient quality (see details in the first data repository), 16 although most did not adequately consider the relationship between the researcher and the participants.
Two overarching programme theories emerged from our review of the studies: (i) a refined version of the classic action cycle, which explains how functional maternal and perinatal death surveillance and response systems reduce maternal and perinatal mortality ( Fig. 3 and Table 2; full table in the second data repository); 79 and (ii) the vicious cycle, which explains how dys-functional systems can fail to achieve their intended objectives, or worse, lead to unintended harmful outcomes ( Fig. 4 and Table 3; full table in the second data  repository). 79

Action cycle
Outcomes Successful outcomes of maternal and perinatal death surveillance and response included implementation of positive changes, especially at the facility level, such as improvements in quality of care, behavioural changes and targeted actions to address specific issues. Two studies 41,50 were linked to quantitative studies 8,80 demonstrating reductions in mortality.

Mechanisms
Three key mechanisms led to implementation of positive change.

Implementation of recommendations
Formulation and implementation of effective recommendations are commonly assumed to be the only mechanism of action for maternal and perinatal death surveillance and response. 4 They are underpinned by a relatively complicated chain of events ( Fig. 3 and Table 2). Most examples of effective responses were targeted actions implemented in individual facilities. 25 Although WHO guidelines recommend that aggregated data be analysed at district and national levels to identify, recommend and implement higher-level solutions, 6 documented examples of these actions were rare. 21

Learning from case discussions
Learning from mistakes was a powerful behaviour-change mechanism mentioned by several respondents and was facilitated by a learning environment in the facility 47 and community-based review meetings. 35 Behaviour change was also motivated by the emotional experience of hearing the stories about the maternal and perinatal deaths and how these cases had been (mis)managed. 39,62,75

Increased vigilance
This learning, and the review process itself, were reported to make health workers more vigilant in their daily practice, because they knew that if a

Contexts
Underpinning these mechanisms is a learning environment (Fig. 3), where people feel safe to honestly report deaths, disclose accurate information and openly discuss the cases, including any mistakes in their management. 47,53,56,74 Learning environments assure confidentiality, anonymity and separation from blame or any disciplinary process. Although several respondents recommended legal protection at the national level to prevent data from maternal and perinatal death surveillance and response being used in litigation, only South Africa had enacted this protection which "has been ratified by relevant judicial bodies. " 81 In the absence of such legal protection, the next best context was an audit charter; members of the maternal and perinatal death surveillance and response committee were required to sign this charter to indicate their commitment to the principles of good conduct of clinical audit, including confidentiality, before participating in any session. 38,75 Good leadership and chairing of meetings at the facility level also create a safe space for open discussion ( Fig. 3 and Table 2). 40 Adequate resources enable implementation of the process and of recommendations.

Vicious cycle
In contrast, many studies reported elements of a vicious cycle resulting in dysfunctional death surveillance and response ( Fig. 4 and Table 3).

Outcomes
The commonest negative outcome was simply the lack of any change. 49,77 In some cases, the maternal and perinatal death surveillance and response process stopped. 72 Two studies reported on the maternal and perinatal death review process in the same urban district hospital in Burkina Faso in 2004-2005 75 and 2015-2016. 77 Although this was one of the pioneer hospitals, in the second study an informant from the district level reported, "I know the team is there, but I don't believe that this committee ever has a session." 77 More worryingly, a few studies reported harmful outcomes. First, staff shortages could be worsened as staff became afraid to work on the labour ward, 28,62 some took several weeks off work after an upsetting review 73 and junior doctors were deterred from choosing obstetrics as a career. 73 Second, some staff practised defensive medicine such as inappropriate referral of unstable patients at high risk of death. 51,73 Third, an extreme example given was refusal of admission to referral facilities of women who seemed likely to die, possibly to avoid damaging mortality statistics. 76 Fourth, serious repercussions were reported for a woman who had com-

Mechanisms
Fear of blame (and of negative consequences such as disciplinary action or litigation) was the most pervasive mechanism. This fear inhibited learning and participation, and led to disengagement from the maternal and perinatal death surveillance and response process at all stages, which resulted in underreporting, inaccurate data, inadequate participation in reviews, inadequate formulation of solutions and avoidance of responsibility. Fear of blame usually resulted from insufficient confidentiality or anonymity, and the death review process not being separated from disciplinary procedures. 76 Telling participants that the process was blame-free was insufficient to allay fears when senior managers were present who would also be in charge of disciplinary procedures 53,76 or when litigation against health workers was increasing. 73 Inadequate preparation enabled the blame culture to persist as staff were unsure how to implement maternal and perinatal death surveillance and response. 22 Many references were made to: inadequate or unavailable guidance; lack of training; poor leadership; charters not being signed; 38  than being integrated with other public health systems. 29,45 Under-reporting of deaths was often due to fear of blame or other negative consequences, such as reduced funding, 21,53,73,76 but also resulted from social stigma, 33 cultural beliefs, nonmandatory reporting 53 and political pressure. 51,72,73 Inaccurate and/or incomplete information undermines the review process. Although poor record-keeping was common, 42,53 several reports noted deliberate falsification of records 25,57,70,73 or misclassification of deaths 70,76 to avoid blame or reputational damage. Sometimes staff did not collect the information because they simply did not have time 45 or the correct forms, 60 or did not understand the purpose of maternal and perinatal death surveillance and response. 49 Inadequate review was the inevitable consequence of inaccurate information: "it is essentially garbage in, garbage out." 55 Reviews could also fail if: the committee did not include all necessary stakeholders; some key stakeholders did not attend; stakeholders attended but felt unable to participate because of disengagement or hierarchical relationships; or stakeholders feared blame or attempted to shift blame to others. 26,36,40 Inadequate recommendations result from inadequate review. Poor chairing, lack of focus in review meetings and blame-shifting 26,36,43 also impaired the formulation of effective recommenda-tions. 40 Sometimes meetings focused on accurately determining the cause of death at the expense of formulating effective recommendations. 45 Non-implementation of recommendations was inevitable if they were unachievable. Furthermore, implementation rarely happened if: responsibility for implementation was unclear; 44 the individuals responsible for implementation were not involved in the review; 21,38,54,60 recommendations were not fed back to those responsible for implementation; 30,44 implementers avoided taking responsibility; 40,43 or no mechanism was in place to follow up on implementation. 76,77 Insufficient resources also prevented implementation. 25,36,48,72  Demotivation and disengagement resulted from non-implementation and the perception that the process was not achieving its intended aim. 25,52,54 The lack of any incentives was also demotivating. 24,25,76 Lack of sustainability resulted from over-dependence on foreign aid, 38,46,72 or on a small number of staff. 21 If no team or mechanism existed for training new staff, the process would stop when key staff were absent or left, which was common given high staff turnover in many settings.

Contexts
Three key contexts triggered the mechanisms leading to dysfunctional maternal and perinatal death surveillance and response. First, a blame culture heightens fear of blame, which was widely reported in health workers and families being questioned about a death. This problem was exacerbated in countries under an authoritarian system, where confidentiality was not guaranteed 75 and the maternal and perinatal death surveillance and response process was not separated from litigation or disciplinary procedures, 51 where families had no avenues for complaining apart from litigation, 73 and where health workers could be detained by the police after maternal or child deaths. 22,73,82 Paradoxically, high-level political commitment to reducing maternal mortality sometimes resulted in pressure on health workers not to report deaths. 51,72,73 Second, insufficient resources prevented: adequate preparation for maternal and perinatal death surveillance and response; adequate data collection; convening of review meetings; and implementation of recommendations. 60,63 Staff shortages meant that key stakeholders could not leave clinical duties to complete investigations or attend meetings 34,44,50,53 and also that anonymity was not possible in review meetings. 67 In some cases, sufficient forms were not available. 60 Staff were often expected to attend meetings during lunch breaks or after work, but were reluctant to do so if no refreshments or financial compensation were provided. 25 Lack of any budget for maternal and perinatal death surveillance and response also made it difficult to implement many recommendations; 44 for example buying new equipment or holding community meetings.
Third, poor leadership at facility, district or national levels perpetuated unfavourable environments and behaviour, including: the blame culture, 63 a general lack of commitment to maternal and perinatal death surveillance and response, 54,72 under-resourcing, frequent staff turnover, poor preparation for maternal and perinatal death surveillance and response, insufficient communication, poor chairing of surveillance and response meetings, 52 non-implementation and follow-up of recommendations, and general demotivation. 42

Discussion
We found 59 qualitative studies investigating implementation of maternal and perinatal death surveillance and response in low-and middle-income countries. To achieve a functional action cycle with positive outcomes, such as reduced mortality and improved quality of care, a blame-free learning environment needs to be nurtured, clearly separated from litigation and disciplinary processes. Although WHO guidelines state that a mortality audit "is not a solution in itself," 4 several studies found that a learning environment enables not only the formulation of achievable recommendations, but also direct learning from the process and a healthy vigilance regarding quality of care. Good outcomes motivate staff to remain engaged, making the process sustainable.
In stark contrast, maternal and perinatal death surveillance and response often became a dysfunctional vicious cycle in the context of a blame culture, poor leadership and insufficient resources. Fear of blame inhibits all steps of the surveillance and response cycle. This fear not only inhibits intended outcomes but can also provoke harmful outcomes such as falsification of information, worsened staff shortages, inappropriate referrals or even the refusal to accept referrals, with the intention of avoiding responsibility. Our findings contradict the conclusions of the 2016 study that reported disciplinary action, legal redress and social reprisals were the most important mechanisms for accountability: 13 we found that disciplinary action, litigation and social reprisals were likely to result in disengagement, lack of learning and negative outcomes.
While the literature search was comprehensive and the realist approach provided a useful framework for understanding causal pathways, the maternal and perinatal death surveillance and response process is cyclical rather than linear and a particular issue could be a context, a mechanism or an outcome at different points in the cycle. While other study types may also contain useful information, we only included qualitative studies because we were interested in the subjective experiences of those participating in maternal and perinatal death surveillance and response. However, social desirability bias is likely to be an important weakness of any research in contexts where freedom of speech is limited and a fear of blame exists, both of which may prevent participants from being completely open and honest about their experiences. 51 Nevertheless, our review included several articles giving candid accounts of dysfunctional maternal and perinatal death surveillance and response processes in several settings. As the bias is likely to favour positive accounts, the reality could be worse than has been reported.
Most studies did not adequately consider the relationship between researchers and interviewees, and it is likely that this relationship influenced reported perceptions of the success, or failure, of the maternal and perinatal death surveillance and response process. Furthermore, implementation of maternal and perinatal death surveillance and response may have both positive and negative aspects in a single country or study.
Our results have implications for policy and practice. First, it is imperative to ensure that necessary preparations have been made before attempting to implement a maternal and perinatal death surveillance and response process. The essential conditions to ensure an effective process are good leadership, willingness and ability to provide a safe, blame-free learning environment and sufficient resources to support the surveillance and response process and implementation of its recommendations. In the context of a blame culture (including litigation and disciplinary procedures), poor leadership and insufficient resources, the process could do more harm than good. Turning a vicious cycle into an action cycle can be more difficult than starting the whole process from scratch, because fear of blame can persist for a long time. 53 Second, direct learning from review meetings has been ignored as an important mechanism by many implementers.
Thus, participatory review meetings on site and involving as many relevant staff as possible are likely to be more effective at promoting positive behaviour change than remote committee meetings with only a small number of participants.
Third, to evaluate maternal and perinatal death surveillance and response, it is important to assess not only the level of implementation of recommendations, but also whether participants are learning from the process, changing their own practice and seeing positive changes. Monitoring for possible adverse events of the process is also important, such as inappropriate referrals or worsening staff shortages. Monitoring and evaluation focusing on death reporting and cause of death classification may detract from the response component to improve outcomes.
Fourth, an adaptable toolbox of strategies to improve implementation of maternal and perinatal death surveillance and response would be valuable, based on experiences identified through this review as well as behaviour-change theory.
Our findings revealed priorities for future research. First, an intervention to improve implementation of maternal and perinatal death surveillance and response could be co-created with teams already conducting this process in low-income contexts, based on their experience and findings from this review.
Scarce resources should not be a barrier to implementation, as several examples of effective review processes in low-and middle-income countries exist. 8-10 A behavioural science approach should be taken to planning and optimizing the intervention, for example using the person-based approach, 83 with members of death review committees in different settings. Of particular importance would be to evaluate whether such an intervention can shift a vicious cycle into a positive action cycle.
Second, more research is needed to understand how to achieve the optimal balance between a blame-free anonymous process, while maintaining accountability. 47 Although WHO has suggested high-level strategies to minimize the blame culture, 5,84 challenges exist because a completely blame-free, anonymous process may also remove accountability and responsibility for implementing actions, 73 while a focus on accountability may instil fear of blame. 73 Completely removing blame from the maternal and perinatal death surveillance and response process is almost impossible, because negligence will be uncovered and will need to be tackled. 57 Although disciplinary procedures should be kept separate from maternal and perinatal death surveillance and response, in practice this separation may be impossible to achieve in district hospitals and communities where the head of the maternity unit is probably responsible for both disciplinary procedures and the surveillance and response process. A certain level of accountability and vigilance is one of the key mechanisms for a maternal and perinatal death surveillance and response system to achieve its objectives. A sensitive, inclusive death review process could provide a way to address concerns of bereaved families and sensitively inform them about their loss; this approach is important to explore, as it could reduce conflict and unjustified blame of individual health workers. 70,73 In conclusion, maternal and perinatal death surveillance and response can be an effective behaviour-change quality-improvement intervention even in low-and middle-income settings with limited resources, provided the process is conducted in a largely blame-free learning environment, supported by good leadership and sufficient resources.

Systematic reviews
Maternal and perinatal death surveillance Merlin L Willcox et al.

Resumen
Vigilancia y respuesta a la mortalidad materna y perinatal: una revisión sistemática de los estudios cualitativos Objetivo Comprender las experiencias y percepciones de las personas que implementan la vigilancia y la respuesta a la mortalidad materna o perinatal en los países de ingresos bajos y medios, y los mecanismos por los que este proceso puede alcanzar los resultados previstos. Métodos En junio de 2022, se realizaron búsquedas sistemáticas en siete bases de datos para encontrar estudios cualitativos de las partes interesadas que implementan la vigilancia y la respuesta a la mortalidad materna o perinatal en países de ingresos bajos y medios. Dos revisores analizaron de forma independiente los artículos y evaluaron su calidad. Se utilizó la síntesis temática para derivar temas descriptivos y un enfoque realista para comprender las configuraciones de contexto, mecanismo y resultado. Resultados Cincuenta y nueve estudios cumplieron los criterios de inclusión. Los resultados satisfactorios (mejora de la calidad de la atención o reducción de la mortalidad) se sustentaron en un ciclo de acción funcional. Los mecanismos para una vigilancia y respuesta eficaces a la mortalidad incluyeron el aprendizaje, la vigilancia y la aplicación de recomendaciones que motivaron un mayor compromiso. El contexto clave para hacer posible una vigilancia y respuesta eficaz a la mortalidad fue un entorno de aprendizaje libre de culpa con un buen liderazgo. Los resultados insuficientes (falta de mejora en la atención y la mortalidad e interrupción de la vigilancia y la respuesta a la mortalidad) fueron el resultado de un círculo vicioso de falta de notificación, datos inexactos y revisión y recomendaciones inadecuadas, que condujeron a la desmotivación y la falta de compromiso. Se notificaron algunos desenlaces perjudiciales, como las derivaciones incorrectas y una mayor falta de personal, que se debieron al miedo a las consecuencias negativas, como la culpa, las medidas disciplinarias o los litigios. Conclusión Entre los requisitos necesarios para que la vigilancia y la respuesta a la mortalidad materna o perinatal sean eficaces se encuentran los siguientes: separación del proceso de los litigios y los procedimientos disciplinarios; directrices y formación exhaustivas; recursos adecuados para aplicar las recomendaciones; y una supervisión de apoyo que permita el aprendizaje seguro.